The growing caseload of chronic life-long conditions calls for a move towards full self-management in low-income countries

<p>Abstract</p> <p>Background</p> <p>The growing caseload caused by patients with chronic life-long conditions leads to increased needs for health care providers and rising costs of health services, resulting in a heavy burden on health systems, populations and individuals. The professionalised health care for chronic patients common in high income countries is very labour-intensive and expensive. Moreover, the outcomes are often poor. In low-income countries, the scarce resources and the lack of quality and continuity of health care result in high health care expenditure and very poor health outcomes. The current proposals to improve care for chronic patients in low-income countries are still very much provider-centred.</p> <p>The aim of this paper is to show that present provider-centred models of chronic care are not adequate and to propose 'full self-management' as an alternative for low-income countries, facilitated by expert patient networks and smart phone technology.</p> <p>Discussion</p> <p>People with chronic life-long conditions need to 'rebalance' their life in order to combine the needs related to their chronic condition with other elements of their life. They have a crucial role in the management of their condition and the opportunity to gain knowledge and expertise in their condition and its management. Therefore, people with chronic life-long conditions should be empowered so that they become the centre of management of their condition. In full self-management, patients become the hub of management of their own care and take full responsibility for their condition, supported by peers, professionals and information and communication tools.</p> <p>We will elaborate on two current trends that can enhance the capacity for self-management and coping: the emergence of peer support and expert-patient networks and the development and distribution of smart phone technology both drastically expand the possibilities for full self-management.</p> <p>Conclusion</p> <p>Present provider-centred models of care for people with chronic life-long conditions are not adequate and we propose 'full self-management' as an alternative for low-income countries, supported by expert networks and smart phone technology.</p

The Need for a Dynamic Approach to Health System-Centered Innovations; Comment on “What Health System Challenges Should Responsible Innovation in Health Address? Insights From an International Scoping Review”

Lehoux and colleagues plea for a health systems perspective to evaluate innovations. Since many innovations and their scale-up strategies emerge from processes that are not (centrally) steered, we plea for any assessment with a dynamic, instead of a sequential, approach. We provide further guidance on how to adopt such dynamic approach, in order to better un-derstand and steer innovations for better health systems. A systems-level challenge is constituted by interactions and feedback loops between different actors and components of the health system. It is therefore essential to explore both the entry-point of innovation and the interactions with other components. If innovation is regarded as an injection of resources and opportunities into a health system, this system needs to have the capacity to transform these into desired outputs, the ‘absorption capacity.’ The highly organic diffusion of innovation in complex adapative systems cannot be easily controlled, but the system behaviours can be analysed, with occurance of phenomena such as path dependence, feedback loops, scale-free networks, emergent behaviour and phase transitions. This helps to anticipate unintended consequences, and to engage key actors in ongoing problem-solving and adaptation. By adopting a prospective approach, responsible innovation could set in motion prospective policy evaluations, which on the basis of iterative learning would allow decisionmakers to continuously adapt their policies and programmes. Priority-setting for innovation is an essentially political process that is geared towards consensus-building and grounded in values

An interpretative phenomenological analysis of the lived experience of people with multimorbidity in low- and middle-income countries

People living with multimorbidity (PLWMM) have multiple needs and require long-term personalised care, which necessitates an integrated people-centred approach to healthcare. However, people-centred care may risk being a buzzword in global health and cannot be achieved unless we consider and prioritise the lived experience of the people themselves. This study captures the lived experiences of PLWMM in low- and middle-income countries (LMICs) by exploring their perspectives, experiences, and aspirations.We analysed 50 semi-structured interview responses from 10 LMICs across three regions—South Asia, Latin America, and Western Africa—using an interpretative phenomenological analysis approach.The bodily, social, and system experiences of illness by respondents were multidirectional and interactive, and largely captured the complexity of living with multimorbidity. Despite expensive treatments, many experienced little improvements in their conditions and felt that healthcare was not tailored to their needs. Disease management involved multiple and fragmented healthcare providers with lack of guidance, resulting in repetitive procedures, loss of time, confusion, and frustration. Financial burden was exacerbated by lost productivity and extreme finance coping strategies, creating a vicious cycle. Against the backdrop of uncertainty and disruption due to illness, many demonstrated an ability to cope with their conditions and navigate the healthcare system. Respondents’ priorities were reflective of their desire to return to a pre-illness way of life—resuming work, caring for family, and maintaining a sense of independence and normalcy despite illness. Respondents had a wide range of needs that required financial, health education, integrated care, and mental health support.In discussion with respondents on outcomes, it appeared that many have complementary views about what is important and relevant, which may differ from the outcomes established by clinicians and researchers. This knowledge needs to complement and be incorporated into existing research and treatment models to ensure healthcare remains focused on the human and our evolving needs

Testing a self-determination theory model of healthy eating in a South African township

Type 2 diabetes (T2D) is one of the leading causes of death and disability, and its prevalence has been growing rapidly in sub-Saharan Africa (International Diabetes Federation, 2017). In response to this T2D pandemic, engaging in healthy lifestyle activities such as healthy eating, can substantially reduce the risk of T2D onset and complications (International Diabetes Federation, 2017). However, maintaining a healthy diet has been shown challenging and motivation is believed to be a crucial factor, also because the benefits are often not immediately apparent (Kwasnicka et al., 2019)

Scaling-up integrated type-2 diabetes and hypertension care in Cambodia: what are the barriers to health system performance?

BackgroundNon-communicable diseases (NCDs) such as type-2 diabetes (T2D) and hypertension (HTN) pose a massive burden on health systems, especially in low- and middle-income countries. In Cambodia, to tackle this issue, the government and partners have introduced several limited interventions to ensure service availability. However, scaling-up these health system interventions is needed to ensure universal supply and access to NCDs care for Cambodians. This study aims to explore the macro-level barriers of the health system that have impeded the scaling-up of integrated T2D and HTN care in Cambodia.MethodsUsing qualitative research design comprised an articulation between (i) semi-structured interviews (33 key informant interviews and 14 focus group discussions), (ii) a review of the National Strategic Plan and policy documents related to NCD/T2D/HTN care using qualitative document analysis, and (iii) direct field observation to gain an overview into health system factors. We used a health system dynamic framework to map macro-level barriers to the health system elements in thematic content analysis.ResultsScaling-up the T2D and HTN care was impeded by the major macro-level barriers of the health system including weak leadership and governance, resource constraints (dominantly financial resources), and poor arrangement of the current health service delivery. These were the result of the complex interaction of the health system elements including the absence of a roadmap as a strategic plan for the NCD approach in health service delivery, limited government investment in NCDs, lack of collaboration between key actors, limited competency of healthcare workers due to insufficient training and lack of supporting resources, mis-match the demand and supply of medicine, and absence of local data to generate evidence-based for the decision-making.ConclusionThe health system plays a vital role in responding to the disease burden through the implementation and scale-up of health system interventions. To respond to barriers across the entire health system and the inter-relatedness of each element, and to gear toward the outcome and goals of the health system for a (cost-)effective scale-up of integrated T2D and HTN care, key strategic priorities are: (1) Cultivating leadership and governance, (2) Revitalizing the health service delivery, (3) Addressing resource constraints, and (4) Renovating the social protection schemes

Implementation barriers for mHealth for non-communicable diseases management in low and middle income countries: a scoping review and field-based views from implementers.

Background: Mobile health (mHealth) has been hailed as a potential gamechanger for non-communicable disease (NCD) management, especially in low- and middle-income countries (LMIC). Individual studies illustrate barriers to implementation and scale-up, but an overview of implementation issues for NCD mHealth interventions in LMIC is lacking. This paper explores implementation issues from two perspectives: information in published papers and field-based knowledge by people working in this field. Methods: Through a scoping review publications on mHealth interventions for NCDs in LMIC were identified and assessed with the WHO mHealth Evidence Reporting and Assessment (mERA) tool. A two-stage web-based survey on implementation barriers was performed within a NCD research network and through two online platforms on mHealth targeting researchers and implementors. Results: 16 studies were included in the scoping review. Short Message Service (SMS) messaging was the main implementation tool. Most studies focused on patient-centered outcomes. Most studies did not report on process measures and on contextual conditions influencing implementation decisions. Few publications reported on implementation barriers. The websurvey included twelve projects and the responses revealed additional information, especially on practical barriers related to the patients' characteristics, low demand, technical requirements, integration with health services and with the wider context. Many interventions used low-cost software and devices with limited capacity that not allowed linkage with routine data or patient records, which incurred fragmented delivery and increased workload. Conclusion: Text messaging is a dominant mHealth tool for patient-directed of quality improvement interventions in LMIC. Publications report little on implementation barriers, while a questionnaire among implementors reveals significant barriers and strategies to address them. This information is relevant for decisions on scale-up of mHealth in the domain of NCD. Further knowledge should be gathered on implementation issues, and the conditions that allow universal coverage

Motivational determinants of physical activity in disadvantaged populations with (pre)diabetes: a cross-cultural comparison

Background Understanding motivational determinants of physical activity (PA) is essential to guide the implementation of PA at individual and population level. Knowledge about the cross-cultural generalizability of these determinants is lacking and they have mostly been studied as separate factors. This study compares a motivational process model across samples from diverse populations with, or at risk of diabetes. Methods Measurement invariance of barrier identified regulation, barrier self-efficacy and social support was assessed in a rural Ugandan sample (n = 712) and disadvantaged samples with high proportions of immigrants in urban South Africa (n = 566) and Sweden (n = 147). These motivational determinants were then compared through multigroup structural equation modeling. Results The studied motivational constructs showed scalar invariance. Latent mean levels of perceived social support and barrier self-efficacy were lower in South Africa and Sweden. Structural models (for different PA outcomes) were not consistent across settings except for the association between perceived social support and identified regulation. Identified regulation was only associated with vigorous PA in Uganda and with moderate PA in South Africa. The association between social support and PA outcomes ranged from weak to not significant and the association between self-efficacy and PA was not significant. Self-reported PA was highest in Uganda and lowest in Sweden. Self-reported vigorous PA was significantly related to lower hemoglobin A1c levels, while moderate PA was not. Conclusions Findings suggest that: 1) it is feasible to compare a motivational process model across diverse settings; 2) there is lower perceived social support and self-efficacy in the urban, migrant samples; 3) identified regulation is a more promising determinant of PA than self-efficacy or social support in these populations; 4) associations between motivational determinants and PA depend on the perceived type and/or intensity of PA; 5) perceived relatedness functions as a basic psychological need across diverse settings; and 6) people’s perception of the PA they perform depends on their perceived level of intensity of PA which would have major implications for health promotion

Prevention and management of type 2 diabetes mellitus in Uganda and South Africa : Findings from the SMART2D pragmatic implementation trial

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Applying systems thinking to identify enablers and challenges to scale-up interventions for hypertension and diabetes in low-income and middle-income countries: protocol for a longitudinal mixed-methods study.

INTRODUCTION: There is an urgent need to reduce the burden of non-communicable diseases (NCDs), particularly in low-and middle-income countries, where the greatest burden lies. Yet, there is little research concerning the specific issues involved in scaling up NCD interventions targeting low-resource settings. We propose to examine this gap in up to 27 collaborative projects, which were funded by the Global Alliance for Chronic Diseases (GACD) 2019 Scale Up Call, reflecting a total funding investment of approximately US$50 million. These projects represent diverse countries, contexts and adopt varied approaches and study designs to scale-up complex, evidence-based interventions to improve hypertension and diabetes outcomes. A systematic inquiry of these projects will provide necessary scientific insights into the enablers and challenges in the scale up of complex NCD interventions. METHODS AND ANALYSIS: We will apply systems thinking (a holistic approach to analyse the inter-relationship between constituent parts of scaleup interventions and the context in which the interventions are implemented) and adopt a longitudinal mixed-methods study design to explore the planning and early implementation phases of scale up projects. Data will be gathered at three time periods, namely, at planning (TP), initiation of implementation (T0) and 1-year postinitiation (T1). We will extract project-related data from secondary documents at TP and conduct multistakeholder qualitative interviews to gather data at T0 and T1. We will undertake descriptive statistical analysis of TP data and analyse T0 and T1 data using inductive thematic coding. The data extraction tool and interview guides were developed based on a literature review of scale-up frameworks. ETHICS AND DISSEMINATION: The current protocol was approved by the Monash University Human Research Ethics Committee (HREC number 23482). Informed consent will be obtained from all participants. The study findings will be disseminated through peer-reviewed publications and more broadly through the GACD network

The promise of digital self-management : a reflection about the effects of patient-targeted e-health tools on self-management and wellbeing

Increasingly, people have direct access to e-Health resources such as health information on the Internet, personal health portals, and wearable self-management applications, which have the potential to reinforce the simultaneously growing focus on self-management and wellbeing. To examine these relationships, we searched using keywords self-management, patient-targeting e-Health tools, and health as wellbeing. Direct access to the health information on the Internet or diagnostic apps on a smartphone can help people to self-manage health issues, but also leads to uncertainty, stress, and avoidance. Uncertainties relate to the quality of information and to use and misuse of information. Most self-management support programs focus on medical management. The relationship between self-management and wellbeing is not straightforward. While the influence of stress and negative social emotions on self-management is recognized as an important cause of the negative spiral, empirical research on this topic is limited to health literacy studies. Evidence on health apps showed positive effects on specific actions and symptoms and potential for increasing awareness and ownership by people. Effects on more complex behaviors such as participation cannot be established. This review discovers relatively unknown and understudied angles and perspectives about the relationship between e-Health, self-management, and wellbeing